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Background Dupuytren's disease is a progressive fibroproliferative disorder which can result in fixed flexion contractures of digits and impaired hand function. Standard treatment involves surgical release or excision followed by post-operative hand therapy and splinting, however the evidence supporting night splinting is of low quality and equivocal. Methods A multi-centre, pragmatic, open, randomised controlled trial was conducted to evaluate the effect of night splinting on self-reported function, finger extension and satisfaction in patients undergoing fasciectomy or dermofasciectomy. 154 patients from 5 regional hospitals were randomised after surgery to receive hand therapy only (n = 77) or hand therapy with night-splinting (n = 77). Primary outcome was self-reported function using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Secondary outcomes were finger range of motion and patient satisfaction. Primary analysis was by intention to treat. Results 148 (96%) patients completed follow-up at 12 months. No statistically significant differences were observed on the DASH questionnaire (0-100 scale: adjusted mean diff. 0.66, 95%CI - 2.79 to 4.11, p = 0.703), total extension deficit of operated digits (degrees: adjusted mean diff 5.11, 95%CI -2.33 to 12.55, p = 0.172) or patient satisfaction (0-10 numerical rating scale: adjusted mean diff -0.35, 95%CI -1.04 to 0.34, p = 0.315) at 1 year post surgery. Similarly, in a secondary per protocol analysis no statistically significant differences were observed between the groups in any of the outcomes. Conclusions No differences were observed in self-reported upper limb disability or active range of motion between a group of patients who were all routinely splinted after surgery and a group of patients receiving hand therapy and only splinted if and when contractures occurred. Given the added expense of therapists' time, thermoplastic materials and the potential inconvenience to patients having to wear a device, the routine addition of night-time splinting for all patients after fasciectomy or dermofasciectomy is not recommended except where extension deficits reoccur. Trial registration The trial was registered as an International Standard Randomised Controlled Trial ISRCTN57079614

Objectives The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. Methods Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of “0,” “5,” and “10” reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of “8” or higher for 80% or more of the panelists. Results Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. Conclusions Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. Clinical relevance statement MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. Key points • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Retrospective Cohort. There is currently no validated patient reported outcome measure (PROM) for Dupuytren's disease. We have performed a retrospective analysis of QuickDASH scores taken before and after surgery for Dupuytren's disease to assess the validity and responsiveness of the QuickDASH and evaluate its suitability to being a PROM for this condition. To determine the eligibility of the QuickDASH score as a Patient Reported Outcome Measure for Dupuytren's disease. Patients were identified from the hand therapy database that had surgery performed between January 2006 and April 2008 who had documented pre- and post-operative QuickDASH scores. 69 patients were identified with complete datasets with a mean change in QuickDASH score of −7.14 (p < 0.001) and an improvement of extension deficit by 68.1 degrees (p < 0.001) at a mean 110 day follow-up. The change in QuickDASH score did not correlate with the change in extension deficit. The effect size was 0.545 and the standardised response mean was 0.580. The QuickDASH is an acceptable PROM for Dupuytren's surgery with limitations. Further research is needed examining PROMs with this common condition. n/a.

The purpose of the study was to explore the relationship between preoperative flexion contracture (FC) and self-reported disability in patients undergoing surgical release by fasciectomy or dermofasciectomy. The study design used was a prospective observational study: Dupuytren’s disease (DD) is a fibroproliferative disorder of the palmar fascia and may lead to functional deficits requiring surgical intervention. Outcomes are usually reported using digital range of motion although recent studies have also included patient-rated outcome measures with the extensively validated Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire commonly used. One hundred fifty-four patients consecutively enrolled in a prospective randomized trial were assessed before surgery for active range of movement using goniometry and self-reported functioning using DASH questionnaire. The small finger was affected in 69% of patients with a mean FC of 77.8 degrees (standard deviation = 43.5°). The mean DASH score was 16 points (range, 0–62). The correlation between severity of FC in all four fingers and DASH was weak ( r = 0.264, p = 0.001). At individual digital level, the correlation between FC and DASH was weak in the index ( r = 0.26), middle ( r = 0.28), and ring ( r = 0.21) fingers but almost absent in the small finger ( r = 0.07). These results show that the relationship between severity of FC and functional disability measured by the DASH questionnaire appear to be very weak or even absent. Level of evidence: Level III prospective cohort study.

The aim of this study was to explore the impact of carpal tunnel syndrome (CTS) on individuals and their expectations of surgical decompression to identify what outcome domains need to be assessed in future clinical trials. This qualitative study used in-depth, face-to-face interviews with nine patients with CTS awaiting surgical decompression. The tape-recorded interviews were transcribed fully, data were coded and categorized independently by two researchers and emerging themes were identified. Patients identified relief of symptoms—tingling, numbness and sleep disturbance, and resumption of important activities—as their most important criteria for judging the success of surgery. Although they recognized the consequences of this disorder were minor in comparison to more serious diseases, patients expressed distress at the impact of this disorder on their quality of life and expressed hope that surgery would address this. The assessment of outcomes of surgical decompression of CTS needs to include measures of symptom resolution as well as of activity limitation and participation restriction. Using existing patient-rated, disease-specific, and region-specific outcome instruments is likely to capture those domains which patients consider important criteria of success.

Objectives The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. Methods Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists. Results Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. Conclusions Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. Key Points • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability . • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability . • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects .

Midcarpal instability (MCI) is the result of complex abnormal carpal motion at the midcarpal joint of the wrist. It is a form of non-dissociative carpal instability (CIND) and can be caused by various combinations of extrinsic ligament injuries that then result in one of several subtypes of MCI. The complex patterns of injury and the kinematics are further complicated by competing theories, terminology and classifications of MCI. Palmar, dorsal, ulna midcarpal instability, and capitolunate or chronic capitolunate instability are all descriptions of types of MCI with often overlapping features. Palmar midcarpal instability (PMCI) is the most commonly reported type of MCI. It has been described as resulting from deficiencies in the ulna limb of the palmar arcuate ligament (triquetrohamate-capitate) or the dorsal radiotriquetral ligaments, or both. Unstable carpal articulations can be treated with limited carpal arthrodesis or the ligamentous defects can be treated with capsulorrhaphy or ligament reconstruction. Conventional radiographic abnormalities are usually limited to volar intercalated segment instability (VISI) patterns of carpal alignment and are not specific. For many years stress view radiographs and videofluoroscopy have been the methods of choice for demonstrating carpal instability and abnormal carpal kinematics respectively. Dynamic US can be also used to demonstrate midcarpal dyskinesia including the characteristic triquetral “catch-up” clunk. Tears of the extrinsic ligaments can be demonstrated with MR arthrography, and probably with CT arthrography, but intact yet redundant ligaments are more difficult to identify. The exact role of these investigations in the diagnosis, categorisation and management of midcarpal instability has yet to be determined.

Background: Techniques incorporating the long head of the biceps tendon (LHBT) into repair of massive irreparable rotator cuff tears (MIRCTs) have been reported to present good clinical outcomes in a short-term follow-up, but there is a lack of studies with longer observation. Purpose: To assess clinical and radiologic results of LHBT redirection with margin convergence repair in patients with MIRCTs in a longer follow-up. Study Design: Case series; Level of evidence, 4. Methods: Patients with at least 2 years of follow-up were enrolled in this retrospective study. Shoulder range of motion, pain per the numeric rating scale, Constant score, and American Shoulder and Elbow Surgeons questionnaire were assessed. True anteroposterior radiographs were assessed regarding acromiohumeral distance and cuff tear arthropathy per Hamada and Favard classifications. Magnetic resonance imaging scans were analyzed regarding fatty infiltration of supraspinatus (SST) and infraspinatus (IST) according to Goutallier classification and LHBT–rotator cuff construct features. Results: The study group involved 45 patients (11 female, 34 male) with a mean age of 65 years (range, 50-77) and mean follow-up of 52 months (range, 24-100). One patient was excluded for reverse shoulder arthroplasty. The mean range of motion was 150° of flexion, 148° of abduction, and 35° of external rotation. The mean pain was 1.0. The mean results were 83.9 in American Shoulder and Elbow Surgeons questionnaire and 71.2 in Constant score. The mean acromiohumeral distance was 5.6 mm (range, 2.0-8.7). On radiographs, cuff tear arthropathy was assessed as grade 1 in 23 patients, grade 2 in 14, grade 3 in 3, and grade 4 in 4. Mild glenoid erosion was observed in 9 patients. Among 35 patients, significant fatty infiltration was observed and graded as 3 in 7 patients for SST and 10 patients for IST and graded as 4 in 1 for SST and 2 for IST. The LHBT was presented intra-articularly in 31 of 35 analyzed magnetic resonance imaging scans and as running directly to the greater tuberosity in 10 of 35. The SST was healed proximally to the LHBT in 28 of 35 patients. One complication (2.2%) and 4 (8.9%) clinical failures were observed. Conclusion: At follow-up >2 years, LHBT redirection provided excellent pain-free range of movement, even though muscle strength deficit persisted. The rate of complications and clinical failures seems to be lower than for other nonarthroplasty treatment options for MIRCT.

APOGEE-2 is a dual-hemisphere, near-infrared (NIR), spectroscopic survey with the goal of producing a chemo-dynamical mapping of the Milky Way Galaxy. The targeting for APOGEE-2 is complex and has evolved with time. In this paper, we present the updates and additions to the initial targeting strategy for APOGEE-2N presented in Zasowski et al. (2017). These modifications come in two implementation modes: (i) \"Ancillary Science Programs\" competitively awarded to SDSS-IV PIs through proposal calls in 2015 and 2017 for the pursuit of new scientific avenues outside the main survey, and (ii) an effective 1.5-year expansion of the survey, known as the Bright Time Extension, made possible through accrued efficiency gains over the first years of the APOGEE-2N project. For the 23 distinct ancillary programs, we provide descriptions of the scientific aims, target selection, and how to identify these targets within the APOGEE-2 sample. The Bright Time Extension permitted changes to the main survey strategy, the inclusion of new programs in response to scientific discoveries or to exploit major new datasets not available at the outset of the survey design, and expansions of existing programs to enhance their scientific success and reach. After describing the motivations, implementation, and assessment of these programs, we also leave a summary of lessons learned from nearly a decade of APOGEE-1 and APOGEE-2 survey operations. A companion paper, Santana et al. (submitted), provides a complementary presentation of targeting modifications relevant to APOGEE-2 operations in the Southern Hemisphere.